The deteriorating patient-physician relationship in India: Is it time to look within?
Shreyak SharmaPublished online on September 11, 2019
The patient-physician relationship in India is in a state of rapid decline with fresh incidents of violence highlighting the scale of the problem. The medical fraternity needs to reflect on certain issues plaguing its conduct with patients and colleagues and embark on steps to address them. In this article, I highlight some major points which could help us arrest the deteriorating trust and heightened violence in hospitals.
Healthcare is the backbone of any country. India is one of the biggest producers of healthcare professionals around the world (1). Earlier, the parents of most youngsters, if asked, would wish for their children to become doctors. This established situation is changing now. Our relationship with the people we serve is deteriorating rapidly, so much so that physical and verbal assault has become part and parcel of practising medicine, especially in government hospitals.
While there are numerous external factors to blame, ranging from political apathy to sensationalism in the media, there are serious internal issues within the fraternity that need to be highlighted and reflected upon. We are at a watershed moment as far as practising medicine is concerned, and the recent increase in attacks on doctors has drawn country-wide condemnation.
The age of consumerism is hereIt is a well-known fact that doctors were considered noble souls and revered as “gods” until very recently. However, the world we live in has changed significantly. The 21st century is the age of consumerism where everyone wants to protect their own interests and get the best service for the fees they pay. Greenhalgh and Wessely (2) argued that patients are independent and rational beings who make economic decisions about their health and medical needs to fulfil their own interests. This has created a power shift in the traditional patient-physician relationship and patients no longer see their doctors as authoritative omniscient figures who cannot be questioned. In this scenario, our first objective is to accept the new order and not expect traditional ways of practising medicine in India to be sufficient for the present and future generations. Akin to patients wanting to prioritise their economic and health interests, physicians also have the right to gain economically from their profession, but not at the cost of medical ethics. While a large majority of physicians treat their patients ethically, a few examples of unethical treatment practices can be devastating for the fraternity and put the integrity of the profession at large in question. Physicians should take cognisance of this fact and urge the whole community to continue doing good work and refrain from actions that might diminish people’s trust in the profession.
Communication and empathyCommunication skills are a vital part of the patient-physician relationship. Be it the lack of focused training in this respect, or the sheer number of patients that doctors have to deal with, Indian physicians have often been accused of rudeness and indifference to their patients. Any honest Indian physician would agree that they may have reacted in a way which could negatively impact the patient’s state of mind, even if there were serious pressures behind it. Empathy and humility are important pillars of the physician-patient relationship and have been scientifically proven to improve the healthcare encounter, patient compliance and outcomes (3). It is high time that the medical curriculum lays a strong emphasis on teaching communication, empathy, humility, and methods to carefully tackle highly charged hospital environments and difficult patients. This sort of training is severely lacking and immediate efforts to integrate it into the curriculum would go a long way towards addressing these issues. Case presentations in medical colleges are mostly limited to summarising the patient’s condition in front of teachers, with little emphasis on how the patient interview was conducted. It would be worthwhile to conduct structured patient encounters where the entire patient-student encounter is monitored and reviewed by faculty.
Need for respectful interaction
Of the many issues plaguing our fraternity, none is as significant as mutual conduct amongst physicians. Medical colleges are the cradle of future doctors and only a few worthy applicants get an opportunity to fulfill their dreams. However, these youngsters are soon subjected to the harsh realities of medical life, one of which is the concept of seniority. It is this concept of seniority and perceived superiority arising from it that disregards respect for each other and promotes verbal abuse and disdain, right from the first year. Cut to residency, and the same approach is evident, albeit this time in the presence of patients. It is a common sight for patients to see a senior doctor being angry and treating a junior colleague with utter disrespect and sometimes, subjecting them to blatant humiliation. This creates a negative impact on the patients as they start seeing junior doctors as inefficient and in turn treat them in a disrespectful manner.
Residents are in the line of fire daily, are expected to work 16 hours a day and still make time for studying, journal clubs, and thesis. A person dealing with such stress, in addition to the rebukes while on rounds, will not be in a positive frame of mind. A lot of this frustration gets further projected onto patients and our conversations with them, further deteriorating that relationship. A periodic assessment and acknowledgement of challenges faced by them and an attempt at counselling, if indicated, may prove to be the crucial missing tool for residents’ health. It will also help to identify doctors suffering from mental health issues like depression and provide timely intervention (4, 5). A change in our own attitudes towards each other can be a significant step in the right direction for the medical fraternity.
Time to focus on emergency medicine?
It has been well established that most cases of healthcare violence occur in the emergency department (6, 7). These adrenaline-packed environments are often left to medical officers and interns to handle. The lack of proper triage and ability to handle patients and their relatives leads to verbal and physical conflict. The Medical Council of India accepted the proposal to introduce Emergency Medicine (EM) as a specialty in 2009 (8); but until now, only a handful of states have implemented it. Introducing dedicated and trained EM residents who are sensitised and taught to handle tough situations, charged relatives, and “breaking bad news” is the need of the hour to enable better handling of emergency rooms and trauma centers.
This is an important time for the healthcare community in India and it is vital that drastic measures be taken by the government, professional bodies, civil society, and the media to preserve trust in the system and resolve all outstanding issues related to healthcare. While we can only hope that the Government improves health infrastructure and investment, and the media refrains from its TRP-driven attempts to sensationalise, such expectations are at best idealistic. It is up to us to introspect and make changes that might help in promoting a safer and more efficient work environment.
- Central Bureau of Health Intelligence, Ministry of Health and Family Welfare. National Health Profile. New Delho: CBHI; 2018. p. 217-28
- Greenhalgh T, Wessely S. ‘Health for me’: a sociocultural analysis of healthism in the middle classes. Br Med Bull. 2004. 69:197-213
- Ruberton PM, Huynh HP, Miller TA, Kruse E, Chancellor J, Lyubomirsky S The relationship between physician humility, physician-patient communication, and patient health. Patient Educ Couns. 2016 Jul; 99(7):1138-45.
- Sharp M, Burkart KM. Trainee wellness: why it matters, and how to promote it. Ann Am Thorac Soc. 2017 Apr;14(4):505-12
- Daskivich TJ, Jardine DA, Tseng J, Correa R, Stagg BC, Jacob KM, Harwood JL. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015 Mar;7(1):143-7
- Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med. 2016 Apr 26;374(17):1661-9.
- Chauhan V, Galwankar S, Kumar R, Raina SK, Aggarwal P, Agrawal N, SV, Bhoi S, Kalra OP, Soans ST, Aggarwal V, Kubendra M, Bijayraj R, Datta, Srivastava RP. The 2017 Academic College of Emergency Experts and Academy of Physicians of India position statement on preventing violence against health-care and vandalization of health-care facilities in India. Int J Crit Illn Inj Sci. 2017 -Jun; 7(2):79-83
- Sriram V, Hyder AA, Bennett S. The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India. Int J Health Policy Manag. 2018 Nov; 7(11):993-1006.